NP- OR

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City Name of Patient:J.R.. Age: 44

Ward/Bed No.:OSW

Clustered Cues

Nursing Diagnosis

12/8/2016

Acute related Surgical procedure

2:00 pm Guarding behavior on postop site; Self-focused as noted

Rationale pain to

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.

Source: Nurse’s Pocket Guide, Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr Page 521 Student’s name: Lene Therese T. Losbañes Clinical Instructor: Dodge Churchill P. Toledo, R.N.

Attending Physician: Dr. M.J. Impression/Diagnosis:

Objectives of Care/ Outcome Criteria After 1 hour, patient must have: 1. Report pain is relieved or controlled; 2. Verbalize nonpharmacolo gical methods that provide relief; and 3. Demonstrate use of relaxation skill as indicated for individual situation.

Nursing Interventions 1. Observe nonverbal cues and pain behaviors and other objective defining characteri stics, as noted; 2. Monitor skin color and vital signs; and 3. Provide comfort measure such as a quiet environme nt and calm activities.

Rationale 1. Observations may not be congruent with verbal reports and may be only an indicator of present when client is unable to verbalize; 2. Which are usually altered in acute pain; and 3. To promote nonpharmacolo gical pain managemen t.

Evaluation 12/8/2016 3:00 pm Goals unmet as evidenced by inability To verbalize and demonstrate due to postop condition.

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City Name of Patient:J.R.. Age: 44

Ward/Bed No.:OSW

Clustered Cues

Nursing Diagnosis

Rationale

12/8/2016

Hyperthermia related to post-op fever

Fever above 38ºC (100.4ºF) is common in the first few days after major surgery. Most early postoperative fever is caused by the inflammatory stimulus of surgery and resolves spontaneously. However, postoperative fever can be a manifestation of a serious complication. Fever is a manifestation of cytokine release in response to a variety of stimuli. Fever-associated cytokines, including interleukin (IL)-1, IL-6, tumor necrosis factor (TNF)-alpha, and interferon (IFN)-gamma, are produced by a variety of tissues and cells (algorithm 1). There is some evidence that IL6 is the cytokine most closely correlated with postoperative fever.

2:00 pm 39.3℃ Increased in body temperature above normal range; skin warm to touch

Source: http://www.uptodate.co m/contents/postoperativ

Attending Physician: Dr. M.J. Impression/Diagnosis:

Objectives of Care/ Outcome Criteria After 1 hour, patient must have: 1. Maintain core temperatu re within normal range; 2. Demonstra te behaviors to monitor and promote normother mia;

Nursing Interventions 1. Assess temperatur e an other assessment findings including vital signs; 2. Promote surface cooling by means of undressing; cool environmen t; 3. Monitor any signs of infection; and 4. Encourage patient to maintain bed rest.

Rationale 1. To obtain baseline data; 2. Heat loss by radiation and conductio n; 3. To determine if fever is caused by post-op complicati ons; and 4. To reduce metabolic demands and oxygen consumpti on.

Evaluation 12/8/2016 3:00 pm Goals unmet as evidenced by 39℃. Goals unmet as evidence by inability to demonstrate behaviors to promote normothermia

e-fever

Student’s name: Lene Therese T. Losbañes Clinical Instructor: Dodge Churchill P. Toledo, R.N.